Steffen Fleßa

Life- and person-centred help in Mecklenburg-Western Pomerania, Germany (DelpHi): study protocol for a randomised controlled trial

BackgroundThe provision of appropriate medical and nursing care for people with dementia is a major challenge for the healthcare system in Germany. New models of healthcare provision need to be developed, tested and implemented on the population level. Trials in which collaborative care for dementia in the primary care setting were studied have demonstrated its effectiveness. These studies have been conducted in different healthcare systems, however, so it is unclear whether these results extend to the specific context of the German healthcare system.The objective of this population-based intervention trial in the primary care setting is to test the efficacy and efficiency of implementing a subsidiary support system on a population level for persons with dementia who live at home.Methods and study designThe study was designed to assemble a general physician-based epidemiological cohort of people above the age of 70 who live at home (DelpHi cohort). These people are screened for eligibility to participate in a trial of dementia care management (DelpHi trial). The trial is a cluster-randomised, controlled intervention trial with two arms (intervention and control) designed to test the efficacy and efficiency of implementing a subsidiary support system for persons with dementia who live at home. This subsidiary support system is initiated and coordinated by a dementia care manager: a nurse with dementia-specific qualifications who delivers the intervention according to a systematic, detailed protocol. The primary outcome is quality of life and healthcare for patients with dementia and their caregivers. This is a multidimensional outcome with a focus on four dimensions: (1) quality of life, (2) caregiver burden, (3) behavioural and psychological symptoms of dementia and (4) pharmacotherapy with an antidementia drug and prevention or suspension of potentially inappropriate medication. Secondary outcomes include the assessment of dementia syndromes, activities of daily living, social support health status, utilisation of health care resources and medication.DiscussionThe results will provide evidence for specific needs in ambulatory care for persons with dementia and will show effective ways to meet those needs. Qualification requirements will be evaluated, and the results will help to modify existing guidelines and treatment paths.Trial registrationNCT01401582

Cost comparison of MRSA screening and management – a decision tree analysis

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) infections represent a serious challenge for health-care institutions. Rapid and precise identification of MRSA carriers can help to reduce both nosocomial transmissions and unnecessary isolations and associated costs. The practical details of MRSA screenings (who, how, when and where to screen) remain a controversial issue.MethodsAim of this study was to determine which MRSA screening and management strategy causes the lowest expected cost for a hospital. For this cost analysis a decision analytic cost model was developed, primary based on data from peer-reviewed literature. Single and multiplex sensitivity analyses of the parameters “costs per MRSA case per day”, “costs for pre-emptive isolation per day”, “MRSA rate of transmission not in isolation per day” and “MRSA prevalence” were conducted.ResultsThe omission of MRSA screening was identified as the alternative with the highest risk for the hospital. Universal MRSA screening strategies are by far more cost-intensive than targeted screening approaches. Culture confirmation of positive PCR results in combination with pre-emptive isolation generates the lowest costs for a hospital. This strategy minimizes the chance of false-positive results as well as the possibility of MRSA cross transmissions and therefore contains the costs for the hospital. These results were confirmed by multiplex and single sensitivity analyses. Single sensitivity analyses have shown that the parameters “MRSA prevalence” and the “rate of MRSA of transmission per day of non-isolated patients” exert the greatest influence on the choice of the favorite screening strategy.ConclusionsIt was shown that universal MRSA screening strategies are far more cost-intensive than the targeted screening approaches. In addition, it was demonstrated that all targeted screening strategies produce lower costs than not performing a screening at all.

Modelling lifelong costs of caries with and without fluoride use

Cost-benefit or cost-cost analyses are becoming increasingly important in dentistry. Therefore, the aim of the present study was to evaluate the economic consequences of caries prevention with fluorides. German epidemiological data were used in a system dynamics model to assess the lifelong costs of caries in a population. Without fluoride prevention, lifelong treatment for caries resulted in mean costs of 6,976 euro and a present value of 932 euro per person (5% discounting). In different scenarios of constant, increasing, or decreasing caries-controlling effects, and of limited (age 6-18 yr) or lifelong application, the combination of fluoride salt, fluoride toothpaste, and fluoride gel were most cost-effective. They reduced the costs for caries treatment and prophylaxis to 482, euro or to a present value of 148 euro (5% discounting), when applied from age 6-18 yr, and to 211-213 euro for lifelong use (present value, 5% discounting). In conclusion, a lifelong model of costs of caries demonstrates that the use of fluorides in caries prevention is highly cost-effective.

Delegation of GP-home visits to qualified practice assistants: assessment of economic effects in an ambulatory healthcare centre

BackgroundAgainst the background of a decreasing number of general practitioners (GPs) in rural regions in Germany, the AGnES-concept (AGnES = GP-supporting, community-based, e-health-assisted, systemic intervention) supports the delegation of regular GP-home visits to qualified practice assistants. The concept was implemented and evaluated in different model projects in Germany.To explore the economic effects of this concept, the development of the number of home visits in an ambulatory healthcare centre was analysed and compared with the number of home visits in the surrounding county.MethodsInformation about GP-home visits was derived from reimbursement data of the ambulatory healthcare centre and a statutory health insurance. Information about home visits conducted by AGnES-practice assistants was collected from the project documentation over a time period of 12 consecutive quarter years, four quarter years before the beginning of the project and 8 quarter years while the project was implemented, considering background temporal trends on the population level in the study region.ResultsWithin the ambulatory healthcare centre, the home visits by the GPs significantly decreased, especially the number of medically urgent home visits. However, the overall rate of home visits (conducted by the GPs and the AGnES-practice assistants together) did not change significantly after implementation of the AGnES-concept. In the surrounding county, the home visit rates of the GPs were continuous; the temporal patterns were approximately equal for both usual and urgent home visits.ConclusionThe results of the analyses show that the support by AGnES-practice assistants led to a decrease of GP-home visits rather than an induction of additional home visits by the AGnES-practice assistants. The most extended effect is related to the medically urgent home visits rather than to the usual home visits.

Costing maternal health services in South Tanzania

The following paper presents the methodology and results of a costing exercise of maternal health services in Tanzania. The main objective of this study was to determine the actual costs of antenatal and obstetric care in different health institutions in a district in Tanzania as a basis of more efficient resource allocation. A costing tool was developed that allows the calculation of costs of service units, such as deliveries and antenatal care, and separates these costs from the costs of other services. Time consumed by each activity was used as an allocation key. For that purpose, we recorded the personnel consumption with different time-study methodologies. This approach was tested and implemented in Mtwara Urban District, South Tanzania. The results were analyzed by a spreadsheet program. The paper presents average costs for different costing units of maternal care. Among other findings, we found that the cost of a normal vaginal delivery is US

The cost of dialysis in low and middle-income countries: a systematic review

12.30 in a dispensary and US

Effect of the delegation of GP-home visits on the development of the number of patients in an ambulatory healthcare centre in Germany

6.30 in the hospital—a result that needs explanation, as usually one would expect that hospitals are more cost-intensive than first-line facilities. However, dispensaries are grossly underutilized so that the costs per service unit are rather high. The cost for surgical delivery (only in hospitals) was found to be US

Medication Cost of Persons with Dementia in Primary Care in Germany

69.26 and the average cost per antenatal care consultation (only at dispensaries) was US

Individualisierte Medizin: vom Innovationskeimling zur Makroinnovation

2.50. We conclude that improved planning of elective services is a prerequisite for more effective and efficient use of personnel resources. In addition, the definition of medically and economically sound standards, in particular staffing standards, is critical to make cost analysis an effective management tool to guide rational resource allocation.

Hospital development plans

BackgroundThe cost of dialysis in low and middle-Income countries has not been systematically reviewed. The objective of this article is to systematically review peer-reviewed articles on the cost of dialysis across low and middle-income countries.MethodsPubMed and Embase databases were searched for the year 1998 to March 2013, and additional studies were added from Google Scholar search. An article was included if two reviewers agreed that it had reported cost of dialysis from low and middle-Income countries.ResultsThe annual cost per patient for hemodialysis (HD) ranged from Int